Normal birth or spontaneous vertex delivery?

The declining normal birth rate and increasing Caesarean Section (CS) rates have been a worldwide cause for concern and debate for two decades. In the United Kingdom (UK) normal birth rates have fallen from 70 per cent in the 1970s to 46.7 per cent in 2009 (Birth Choice UK 2011). As normal birth rates continue to fall, researchers and advocates of normality are focusing on the midwife's role in response to this decline. The language and definitions used to classify normality and normal birth are contentious issues leading to confusion for midwives and women. This paper seeks to contribute to the debates around defining and promoting normality.     

Cesarean delivery technique: evidence or tradition? A review of the evidence-based cesarean delivery

Cesarean delivery is the most common surgical procedure performed in the United States, yet the techniques used during this procedure often vary significantly among providers. The purpose of this review was to evaluate and outline current evidence behind the cesarean delivery technique. A search of the PubMed database was conducted using the terms cesarean section and cesarean delivery and the technique of interest, for example, cesarean section prophylactic antibiotics. Few aspects of the cesarean delivery were found to have high-quality consistent evidence to support use of a particular technique. Because many aspects of the procedure are based on limited or no data, more studies on specific cesarean delivery techniques are clearly needed. Providers should be aware of which components of the cesarean delivery are evidence-based versus not when performing this procedure.     

Is the breech presentation and delivery normal or pathological?

The authors share their opinion, comparing their personal experience with the data in the world literature.     

Pediatrician attendance at cesarean delivery: necessary or not?

OBJECTIVE: To determine whether it is necessary for a pediatrician to attend all cesarean deliveries. METHODS: We analyzed a database of 17,867 consecutive deliveries to determine the rates of low Apgar scores in the following three groups of patients: those with vaginal delivery, cesarean delivery using regional anesthesia without fetal indication, and cesarean delivery for fetal indications or using general anesthesia. RESULTS: There was a significantly higher rate of low Apgar scores in the fetal indications or general anesthesia group when compared with vaginal deliveries. Specifically, 35 (5.8%) of 596 cesareans for fetal heart rate abnormality or using general anesthesia had 1-minute Apgars under 4 in contrast to 115 of 10,270 (1.1%) of vaginal deliveries. There was no significantly increased risk for low Apgar scores in the group of cesareans using regional anesthesia for nonfetal indications (33 of 2057, 1.6%). Results were similar for Apgar scores under 7 at 5 minutes. CONCLUSION: Because there is no higher incidence of low Apgar scores in cesarean deliveries using regional anesthesia for nonfetal indications compared with vaginal deliveries, there is no convincing need for pediatrician attendance at such deliveries.     

Previous caesarean or vaginal delivery: Which mode is a greater risk of perinatal death at the second delivery?

OBJECTIVE: To compare the risk of perinatal death after previous caesarean versus previous vaginal delivery, and pre-labour repeat caesarean versus trial of labour after previous caesarean. STUDY DESIGN: Using the data of the Berlin Perinatal Registry from 1993 to 1999, 7556 second parous women with a previous caesarean delivery were compared with 55142 second parous women with a previous vaginal delivery, and those 1435 women with pre-labour repeat caesarean were compared with 6121 women with a trial of labour after previous caesarean delivery. The rates of perinatal death, stillbirth and intrapartum/neonatal death were analysed using multivariable logistic regression to adjust for confounding variables and obstetric history. RESULTS: A previous caesarean delivery was associated with a 40% excess risk of perinatal death and a 52% excess risk of stillbirth (p<0.05); the risk of intrapartum/neonatal death was not significantly increased. There were no significantly higher rates of intrapartum/neonatal death and of stillbirth in women trying a vaginal birth versus pre-labour repeat caesarean. But in most cases of antepartum death, labour was induced for that reason. CONCLUSION: Consulting women about caesarean delivery for maternal request, the increased risk of perinatal death in further pregnancies should be discussed. After a previous caesarean delivery, a careful screening for several risk factors is necessary before recommending a trial of labour.     

Operative vaginal delivery: a cause of birth injury or is it?

Operative vaginal delivery has been maligned since the days of W.J. Little with the word "forceps" becoming nearly synonymous with "Birth Injury" and "Cerebral Palsy." However in his presentation to the Obstetrical Society of London in 1861, Little's emphasis was on difficult labors being the culprit in subsequent disabilities in the offspring. Instrumented deliveries in that era were the end result of a long, obstructed labor performed for maternal benefit and to avoid a destructive procedure to the fetus thus allowing a chance at life. If there had been a normal progress in labor, operative assistance for delivery would not have been needed. Thus, was it the instrument or the obstructed labor that led to fetal injury? In this article, we will review what injuries to the fetus and the mother can be directly attributable to the instrument. We will explore the processes of labor, conduct of labor management, and concurrent fetal factors that can modulate the occurrence of birth trauma. Evidence regarding inexperience and improper use as contributing to injury will also be explored.     

Are maternal serum troponin I levels affected by vaginal or cesarean delivery?

Our objective was to describe the change in the level of troponin I in patients who undergo a vaginal or cesarean delivery. We obtained troponin I levels on admission and 1 hour after delivery in women undergoing vaginal and cesarean deliveries. Exclusion criteria included <37 weeks' gestation, a history of cardiac disease, hypertension, or cardiac symptoms. The troponin I level used to indicate myocardial ischemia was 2.0 ng/mL; levels were analyzed using the Wilcoxon test. The median age of women in the vaginal versus the cesarean group were 25.6 years and 34.4 years, and the median gestational age for both groups was 39.6 weeks. The median troponin I level before and after vaginal delivery was <0.3 ng/mL and before and after cesarean was <0.3 ng/mL. The highest level of troponin I in either group was 0.3 ng/mL. Troponin I is not elevated as a result of undergoing a vaginal or cesarean delivery. We conclude that troponin I may be used as a reliable marker to diagnose myocardial ischemia in postpartum women.     

Crouching or lying-down? The reason of a (uncomfortable) delivery position

Abstract

Through a deep historical and cultural perspective, this article focuses on the revolution that took place in childbirth, due to the introduction of medical knowledge and surgical skills. Ranging from Greek mythology to the Sixties, this contribution analyses the social, scientific and anthropological reasons that led to the desertion of the delivery vertical position in favour of the lying down one.     

The 30-minute decision-to-incision interval for emergency cesarean delivery: fact or fiction?

The objective of this study was to evaluate the effect of the current guideline of 30-minute decision-to-incision interval (D-I) in emergent cesarean delivery (ECD) on neonatal and maternal outcomes. A retrospective chart review was conducted of pregnant women who underwent ECDs between January 1999 and December 2001. The overall median D-I was 20 minutes (range, 5 to 57 minutes). In 83 women (group I), D-I was < or = 30 minutes, and in 28 women (group II), it exceeded 30 minutes. Group I had more neonates with cord pH < 7.00, seizures, encephalopathy, and lower Apgar scores at 1 and 5 minutes than group II, but were not statistically significant. There was no significant difference in neonatal admission to the neonatal intensive care unit or length of stay between the two groups. Maternal complications were higher in group I, but not statistically significant. Although it was achieved in most of the ECDs, the guideline of 30-minute D-I does not seem to improve neonatal nor worsen maternal outcomes.     

Joel-Cohen or Pfannenstiel incision at cesarean delivery: does it make a difference?

OBJECTIVE: To evaluate whether the technique to open the abdomen might influence the operative time and the maternal and neonatal outcome. METHODS: All consecutive women who underwent a cesarean section at a gestational age greater than or equal to 32 weeks were randomly allocated to have either the Joel-Cohen or the Pfannenstiel incision. Exclusion criteria were two or more previous cesarean sections and previous longitudinal abdominal incision. During the study period 366 patients underwent a cesarean delivery. Of these patients, 56 did not meet the inclusion criteria. The remaining patients were allocated to the Joel-Cohen (n = 152) group and to the Pfannenstiel (n = 158) group. Extraction time was defined as the time interval from skin incision to the clamping of the umbilical cord. RESULTS: The total operative time was similar in both groups [Joel-Cohen 32 min (12-60) vs. Pfannenstiel 33 min (18-70)]. The extraction time was shorter in the Joel-Cohen group than in the Pfannenstiel group [190 s (60-600) vs. 240 s (50-600), p = 0.05]. This remained statistically significant after adjustment for confounding variables (Hazard = 1.26, p = 0.05). No difference was found between groups in terms of intraoperative and postoperative complications. No difference was found in the neonatal neurodevelopmental assessment at 6 months of age in relation to the abdominal incision performed. CONCLUSION: The Joel-Cohen method of opening the abdomen at cesarean delivery is faster then the Pfannenstiel technique at delivering the fetus. However, considering the absence of benefits to the mother and the fetus there is no clear indication for performing a Joel-Cohen incision.     

Caesarean or normal vaginal delivery: overview of physicians’ self-preference and suggestion to patients

Purpose  Caesarean delivery in the absence of any medical indications has become a major issue of concern among the women’s health professionals. The patients’ choice of caesarean is influenced by several factors predominating by their physicians’ suggestion. Our objective was to examine factors that may affect the physicians’ responses to patients consulting the mode of delivery. Methods  Questionnaires were posted to 1,000 female obstetricians and gynaecologists practicing in Tehran in winter 2007. Questionnaires included demographic information of physicians and their history of pregnancy and delivery. Finally, they were asked their preferred mode of delivery and the mode they suggest when being consulted by parturient. Results  From 1,000 physicians, 785 cases (78.5%) responded to the survey. The rate of responses in favour of suggesting normal vaginal delivery, Caesarean Section and painless vaginal delivery was 60.8, 25.6 and 13.6%, respectively. There was a correlation between the suggested and the preferred mode of delivery, it means that the physicians mostly suggested their self-preferred mode of delivery to their patients. Conclusions  Physicians normally suggest to their patients as the safe mode of delivery what they prefer for themselves. This preference and subsequent suggestion is influenced by different factors including their age, marital status, and previous modes of delivery. As conclusion, it is inferred that informing a physician to choose the right mode of delivery for herself leads to better suggestions to the patients.     

When should repeat cesarean delivery be scheduled,after two or more previous cesarean deliveries?

Background: The optimal gestational age for a planned high-order cesarean delivery (CD) reflects the balance between the risk of neonatal morbidity and the risk of unscheduled cesarean delivery prior to the scheduled date.

Methods: A retrospective cohort study of 656 women with?≥2 previous CDs were divided in two groups of women based on the gestational age at which the CD was scheduled: "38 group" and "39 group". Medical records were reviewed for demographic, medical and obstetrical history, and for adverse maternal and neonatal outcomes.

Results: The rate of unscheduled CDs was significantly higher among the 39 group (23.2% vs. 12.7%). There were no significant differences in the rate of maternal or neonatal composite adverse outcome between the two groups. The rate of neonatal respiratory morbidity, however, was higher among the 38 group (5.8% vs. 2.1%).Compared with planned CD, unscheduled CD was associated with a similar rate of maternal composite adverse outcome, but with increased rate of neonatal composite adverse outcome (23.3% vs. 8%, respectively). In a multivariable logistic regression analysis we found that this latter association was due to the earlier actual gestational age at delivery in cases of unscheduled versus planned CD.

Conclusions: Planned CD at 39 weeks, rather than at 38 weeks, is associated with more unscheduled CDs, a similar rate of maternal and neonatal composite morbidity, but a decreased rate of neonatal respiratory morbidity.